community by community
O R G A N I Z E G O V E R N A N C E
INTRODUCTION
“Communityship needs to be strengthened in many organizations today.
This does not mean that we have to put it on a pedestal,
in place of leadership. It, too, can be overdone.
After all, witch hunts had their roots in community.
What we need is balance. We would do well, therefore,
to see both forces as working together in a socially responsible way
to get past the insularity that exists in many organizations.
A healthy society balances leadership, communityship, and citizenship.” (19)
Henry Mintzberg (1939 – )
Henry Mintzberg is a professor of Management Studies at McGill University in Montreal. His “The Last Word” Commentary appeared in the July-August 2009 edition of the Harvard Business Review. The citation above is the last paragraph of the Commentary. Can there be any doubt? In one paragraph, does he not summarize the essential challenge for the reform of our nation’s healthcare industry?
In 1968, Senator Robert Kennedy spoke about a wide-spread social disturbance. It has now been worsening for the last 51 years and has destabilized all the strategies for healthcare reform that have been applied. Within the opening quotation from the “MINDLESS MENACE …” Sub-Page of the OVERVIEW Page, Senator Kennedy described his view of the pervasive violence occurring throughout our land. Although healthcare reform is the primary focus for NATIONAL HEALTH, the indirect motives for healthcare reform could also be its support for “A healthy society” and a related reduction in the “mindless menace of violence” that adversely affects the Family of each person within our nation’s neighborhoods, community by community.
This Global Task, ORGANIZE SYSTEMS, defines the leadership structure for the governance that would direct the affairs of NATIONAL HEALTH as it promotes “communityship and citizenship” for the reform of our nation’s healthcare. The capstone of each community’s Survival Commons, its healthcare, requires a revision of the paradigm shift that has occurred since 1960. This level of renewal must withstand many sources of turmoil, not just the pervasive violence in our neighborhoods. The degree of human goodness and strength to promote change still exists in every community. We must seek it out and remind our neighbors and their Extended Families about the fundamental strength that exists in every community to achieve Stable HEALTH For Each Resident Person. The renewal of healthcare itself must be considered systematically, beginning with Primary Healthcare that is equitably available to and ethnographically accessible by each resident person. Every community must begin this process in conjunction with a reduction of the social adversities affecting the Family of too many resident persons. The “Mindless Menace of Violence” should be on the list of social adversities requiring continuous prevention, mitigation, and amelioration.
LEADERSHIP
If NATIONAL HEALTH has an attribute open to honest differences of opinion, it is the process for selecting its initial and, subsequently, its permanent leadership to represent the spectrum of vested interests that will be required for its governance. Also, choosing the optimum size for a group of individuals to successfully govern an institution is not clearly understood. I have chosen nine. Given these uncertainties, the nine Members for the Board of Trustees of NATIONAL HEALTH would each represent, respectively, one of nine groupings of states. Each grouping of States would encompass a roughly equal population of approximately 36,000,000 citizens. The resulting nine groupings of one or more states, including our nation’s protectorates, would coincide with regionally shared, social, and geographic characteristics. Each regional grouping would have its own Regional Council to assist the Board of Trustees in an advice and consent relationship. The Board of Trustees and Regional Councils would share similar characteristics for the spectrum of their member selection attributes.
Eventually, the nine Regional Councils would each establish nine District Coalitions, each formed initially to assure the existence of equitably available Primary Healthcare for each District Coalition of approximately 4 million citizens. A total of 81 District Coalitions would each promote a locally-driven formation of nine or more Community HEALTH Forums for the resident persons within their District. The functions of each Forum would be supported through mentoring and technical assistance by the Associates, i.e. staff employees, of their respective District Coalition. Each Forum would serve a community of between 100,000 and 600,000 (on average 400,000) resident persons, depending on geographic size and population density. All together the nearly 800 Forums would each promote collective action as the basis to defining a Community HEALTH Plan, annually updated, for assuring that equitably available Primary Healthcare is offered to every resident person. Eventually, the nearly 800 Community HEALTH Plans would specify the development of HEALTH SECURITY certified Primary Healthcare throughout their community along with a description of its own Survival Commons, viz. augmented safety net.
The initial Members of the Board of Trustees and Regional Councils would be selected by a temporary, expedient process. This would involve a Governor from the state or group of states associated with each Regional Council achieving the lowest maternal mortality ratio. When all of the District Coalitions within a Region have been operational for two full years, the permanent process for selecting each of the Members for that Regional Council would begin. Once the affairs of NATIONAL HEALTH had stabilized, the Chairman of the Board of Trustees would recommend an applicant to become its President and Chief Executive Officer. The President/CEO would function as an ex officio Member of the Board of Trustees as defined by an Operational Statement approved by the Board of Trustees. Most importantly, the combined Membership of the District Coalitions, Regional Councils, and Board of Trustees would achieve the requisite experience for the continuous acquisition of leadership skills throughout NATIONAL HEALTH.
This proposal requires the Board of Trustees for NATIONAL HEALTH to prepare an annual report for the President and Congress. The annual report would be the basis for proposing any new Congressional action that may be necessary to resolve any barriers to reform encountered by NATIONAL HEALTH. Optimally, these requests would not be controversial and would represent widely supported improvements in the reform process for our nation’s entire healthcare industry.
Locally connected leadership will be a special requirement for each Forum as they formulate their Community HEALTH Plan to mobilize the sources of assets for promoting the capabilities to offer equitably available Primary Healthcare to each resident person. This Plan would 1) eventually specify Primary Healthcare that has achieved HEALTH SECURITY certification and 2) avoid unintended, but potentially divisive, problems associated with provider panels, community anti-trust, intellectual property, neighborhood service areas, physician career commitments, or population shifts.
The basis for the Community HEALTH Plans may eventually require Congressional clarification given the risk of either inaction or anti-competitive activities. As the benefits of enhanced Primary Healthcare begin to mature, the nearly 800 Forums would eventually focus their Community HEALTH Plans on the other community HEALTH deficiencies. These would include a consideration of the current level of community-wide participation in local, regional, and national pre- and post-disaster preparedness. The vast majority of disasters are knowable, except for their exact location, strength, and timing. In one sense, the process of preparedness for the knowably predictable disasters is the most important means to promote the resilience for responding appropriately to the disasters that are not substantially for-see-able, such as an Influenza pandemic.
Eventually, each of the annually revised Community HEALTH Plans would comprise three sections. The first Section would describe the adequacy of its Primary Healthcare: its level of availability as assured cooperatively by its local healthcare institutions, its prevalence of HEALTH SECURITY Certification, and its anticipated future augmentation needs. The second Section would describe the community’s most prominent adversities that are amenable to the use of collective action strategies for their reduction or stabilization, such as 1) early childhood education, 2) adolescent health (suicide, obesity, STD), 3) pain management, or 4) homelessness. Finally, the third Section would describe the readiness of the community’s ability to prevent, mitigate, and ameliorate the effects of knowable disaster events including a written scenario for the steps in place to maintain this readiness, a COMMUNITY MASTER DISASTER PLAN. A nationally sanctioned effort, community by community, to continuously maintain these Community HEALTH Plans should be the most important benefit within healthcare reform as it helps each community revitalize the importance of each person’s Family, the Family’s Extended Family, and the Family’s micro-social networks. Finally, having each community and their adjacent communities compile mutually compatible Community HEALTH Plans may be its most valuable attribute for improving not only every community’s Survival Commons but also its contribution to improving our nation’s social cohesion.
GOVERNANCE
The top two levels of governance would be established based on a plan described within the Congressional Charter and initiated by the President. A Sub-Page of the GOALS Page describes one model for selecting the initial MEMBERS of the Board of Trustees. The President, or a designee, would preside over the initial Meeting of the Board of Trustees at a location defined by the Congressional Charter. Presumably, the initial MEETING would 1) select its Officers and 2) establish the structure and content of the initial OPERATIONAL STATEMENTS including its General Operating Principles and an initial Strategic Projects Plan. A possible model for these two OPERATIONAL STATEMENTS can be found as Sub-Pages of the GOALS Page.
CONGRESSIONAL CHARTER PROVISIONS FOR THIS GLOBAL TASK
A. The Congressional Charter shall define the initial V I S I O N for the affairs of NATIONAL HEALTH beginning with the initial Meeting of the Board of Trustees.
COMMENT For the first ten years, “Stable HEALTH For Each Resident Person“ would represent its V I S I O N. And, its PRINCIPLES would be: Altruism, Trust, Cooperation, Reciprocity, and Excellence.
B. The Congressional Charter shall require NATIONAL HEALTH to achieve three GOALs within 10 years, establish and maintain three national projects to support healthcare reform, and implement a new strategy for arranging community-based collective action
to guide its own population HEALTH needs. The three national projects, the new strategy, and three GOALs shall be achieved within 10 years after the initial Meeting of the Board of Trustees.
1. The three national projects shall be
a. a PRIMARY HEALTHCARE BENEFITS PLAN that defines
the minimum benefits to be covered by all financial sources
for the reimbursement of health care provided to any resident person
for their Basic Healthcare Needs including the options applicable
for the augmented support of HEALTH SECURITY certified
Primary Healthcare.
COMMENT This will likely take several years to finish. The use of multiple layers as a basis for recognizing regional and community institutional needs may be an important attribute of this PLAN to assure its local and regional acceptance. Promoting and improving the financial recognition of each community’s Primary Healthcare may be one of the most important contributions to the overall reform of our nation’s healthcare industry. A broad base of public support will be necessary for the successful completion of the PLAN. Furthermore,
the legitimate concerns about change must be engaged responsively given the complex, institutional, and economic traditions involved.
b. a PRIMARY PHYSICIAN EDUCATION PLAN that
describes the career-long educational stages necessary to assure the availability
of Primary Physicians as required by the PRIMARY
HEALTHCARE BENEFITS PLAN, and
COMMENT As in “a.” above, an initially slow then rapidly evolving means to support and focus the efforts of our nation’s medical schools will be most important. The initial drafts of this PLAN should focus especially on defining a physician’s basic skill-set required for Primary Healthcare. This preparedness should include, especially, the technical and emotional adaptability for managing the breadth and depth of daily uncertainty associated with a person’s Basic Healthcare Needs. This uncertainty is driven by the high level of multiple disruptive processes occurring concurrently to destabilize each resident person’s HEALTH that may be largely unknowable at the time of any health care encounter.
In addition, this PLAN would specify and implement a coordinated post-graduate medical education process for all Primary Physician’s associated with any HEALTH SECURITY certified, Primary Healthcare clinic. Its coordination with the appropriate specialty certification Boards would be most important. A nationally sanctioned process for assuring a stable and adaptable curriculum regarding Stable HEALTH within the world-wide realms of its Resources, Knowledge, and Human Dignity will be necessary for the providers of enhanced Primary Healthcare within each community.
c. a set of criteria necessary for any Primary Healthcare clinic
to demonstrate proficiency as a basis to qualify for
HEALTH SECURITY Certification to receive
augmented financial support;
COMMENT The criteria should create a process that recognizes a clinic’s initial commitment to change as a basis for its immediately improved reimbursement. Subsequently, the annual level of increasing achievement required for continued Certification would be defined for a span of 3-5 years. As NATIONAL HEALTH matures, the initial “professional, non-economic buy-in” phase could be shortened to 1-2 years. The District Coalitions would monitor the Certification process, and NATIONAL HEALTH would use its own resources as may be required for this monitoring.
2. The new strategy shall be recognized for its ability to:
a. sponsor a locally driven, community initiated assurance
that equitable available Primary Healthcare
is offered to each resident person of their community,
b. promote the use of collective action as a collaborative
community tradition to augment its Survival Commons
with an annual Community HEALTH Plan
in association with its adjacent communities, and
c. promote a community-wide global HEALTH monitoring
tool that is reported monthly. AND
3. Three GOALs shall be achieved within ten years or by its substantially steady improvement to:
a. reduce our nation’s annual health spending to 13.0% or less
of our nation’s gross domestic product,
b. reduce our nation’s annual maternal mortality ratio
to 7.0 maternal deaths per 100,000 live births
or less, and
c. achieve ratification of the Congressional Charter by all States.
COMMENT The final GOAL would be more likely if at least 30 States had ratified the Congressional Charter for NATIONAL HEALTH within the first 4 years following the initial Meeting of the Board of Trustees. The GOALs outcome requiremt shall be the calendar year following ten full years of operational status beginning with the initial Meeting of the Board of Trustees.
C. The Board of Trustees shall have the sole authority and responsibility to carry out the affairs of NATIONAL HEALTH as defined by the Congressional Charter. The Board of Trustees shall:
1. establish its affairs according to the Congressional Charter;
COMMENT A Sub-Page of the GOALs Page describes one alternative for inclusion within the Congressional Charter as a basis to appoint the Membership for the initial MEETING of the Board of Trustees.
2. have a non-voting Member selected within three years by the Chairman and
approved by the Board of Trustees for a term of 5 years
as the President and Chief Executive Officer of NATIONAL HEALTH
with eligibility for an additional 5 years for a maximal appointment
of ten years;
COMMENT The initial Chairman may be a logical choice for this responsibility during the first 3 years. The oversight role of the President and Congress should be defined within the Congressional Charter.
3. have 9 Members appointed temporarily that are replaced according to
a permanent selection process defined in the Congressional Charter;
4. have 9 Members appointed permanently beginning 3 years after the initial MEETING
to include at least 5 overlapping Members:
a. one Member selected by the Members of each Regional Council and approved
by the Board of Trustees for equally overlapping terms
of 9 years from their respective Regions,
b. select a Chairman from the current Members, having at least four years remaining
as a Member, and
c. select a Vice-Chairman, having at least two more years remaining as a Member,
by a vote of the Members every two years beginning the third year
after the initial MEETING;
5. establish the Regional Councils according to the following nine groupings of States:
COMMENT For the set of State clusters for NATIONAL HEALTH, I have taken the actual year of Statehood among the States of each respective Regional grouping to determine an average. A rank ordering of these Regions recognizes the earliest versus the later, year of Statehood groupings of States. The protectorates are not included in the average. The State groupings represent citizen populations that average very close to 36 million citizens. See the initial GOVERNANCE Sub-Page for the actual data.
a. Region 1 Central East – 1787: Pennsylvania (1787), New Jersey (1787),
Maryland (1787), Delaware (1788), District of Columbia,
Puerto Rico, U.S. Virgin Islands;
b. Region 2 North East – 1794: Massachusetts (1787), New York (1788),
Connecticut (1788), New Hampshire (1788), Rhode Island (1790),
Vermont (1791), Maine (1820);
c. Region 3 South East – 1804: Georgia (1788), Virginia (1788),
South Carolina (1788), North Carolina (1789), West Virginia (1863);
d. Region 4 Central – 1806: Kentucky (1792), Tennessee (1796),
Ohio (1803), Indiana (1816), Missouri (1821);
e. Region 5 South Central – 1826: Louisiana (1812), Mississippi (1817), Alabama (1819),
Arkansas (1836), Florida (1845);
f. Region 6 North Central – 1841: Illinois (1818), Michigan (1837), Iowa (1846),
Wisconsin (1848), Minnesota (1858);
g. Region 7 Central West – 1850: California (1850);
h. Region 8 South West – 1898: Texas (1845), Oklahoma (1907), Arizona (1912),
New Mexico (1912); and
i. Region 9 North West – 1908: Oregon (1859), Kansas (1861), Nevada (1864),
Nebraska (1867), Colorado (1876), Montana (1880),
North and South Dakota (1889), Washington (1889), Wyoming (1890),
Idaho (1890), Utah (1896), Alaska (1959), Hawaii (1959),
the residents of Samoa and Guam;
6. having a requirement for each Member of the Board of Trustees
that reflects their expertise of applicable experience for at least 25 years:
a. five Members as medical doctors with three of these Members as Primary Physicians,
b. one Member as an independent mental health practitioner who is
not a medical doctor,
c. one Member as an epidemiologist who is not a medical doctor, and
d. two other Members for long-term leadership, especially with
professional skills associated with ethics or behavioral economics
who are each not a medical doctor;
7. Establish an Operational Statement for the affairs of the Regional Councils
whose Members are selected from Nominees recommended
by a District Coalition to the Governor of the Region’s State
with the best level of healthcare accessibility;
COMMENT The Membership requirements of each Regional Council would be similar to the Board of Trustees.
8. Establish an Operational Statement for the affairs of each District Coalition
limiting their responsibilities to a group, on average, of 3-5 million resident persons
residing within the State or States served by their respective Regional Council:
a. A District Coalition may have a portion of their resident persons living
in two States as long as the two States belong to the same
Regional Council,
b. The Members shall be appointed for equally overlapping terms of nine years
by the applicable Regional Council with Members to include:
i. three Primary Physicians,
ii. one BSN/Registered Nurse from an HHS sponsored Community
Health Center,
iii. one from a community public health department,
COMMENT This candidate must have at least a Master’s Degree, preferably in Public Health. ]
iv. one from a medical school as a medical doctor
COMMENT The candidate should have leadership responsibility for curriculum development associated with medical student education.
v. three from the community, and
COMMENT These three might be selected from those counties of a District as divided into three levels of population density. ]
vi. one non-voting, full-time, administrative
support person; AND
COMMENT This person might assume the role of the Vice-Chairman. The person would be appointed by the Chairman of the respective Regional Council for a five-year term and be eligible for an additional 5-year reappointment.
c. Each District Coalition, under the authority of their respective
Regional Council, will establish an Operational Statement
for the affairs of their Community HEALTH Forums.
COMMENT Each Community HEALTH Forum would 1) serve contiguous geographic areas within a District Coalition’s boundary, 2) generally respect county borders, and 3) be responsible initially for promoting the equitably available Primary Healthcare needs of between 100,000 to 600,000 citizens.
9. Establish an Operational Statement for notifying the Board of Trustees
Chairman in case of a vacancy for any Member’s appointment.
A vacancy shall be declared as a result of a majority decision
by the Chairman, Vice-Chairman and the current Member
with the longest length of appointment to the related
Board of Trustees, Regional Council, or District Coalition; AND
10. Locate the home office for the Board of Trustees, Regional Council,
District Coalition or Community HEALTH Forum based on the
same criteria and establish the initial home office for NATIONAL
HEALTH at St. Louis, Missouri:
a. equitable travel time by each respective resident citizen nationally,
regionally, district, and community,
b. equitable travel distance to a medical school or
school of public health, and
c. equitable travel distance to a state’s legislature.
COMMENT The Board of Trustees shall establish an Operational Statement for the home office locations and periodically revise the Operational Statement at least every ten years. Our nation’s population center in 2010 was located southwest of St. Louis about half-way between St. Louis and Springfield and close to the city of Plato, Missouri. ]
D. While maintaining regular consultation with the Regional Councils, the Board of Trustees shall manage the affairs of NATIONAL HEALTH based on an annually revised Strategic Development Plan approved by the Board of Trustees. The advice and consent relationship between the Board of Trustees and the Regional Councils shall require an official review of any Policy or Procedure for the first time and subsequently, for any revision, if the Board of Trustees retained the final Approval Authority of the previously approved Operational Statement.
COMMENT A preliminary draft for the initial Strategic Projects Plan can be found as a Sub-Page of the GOALs Page.
E. After consultation with each Regional Council, the Board of Trustees at any time may authorize its Chairman to submit a request to the President for a Congressional revision of existing Federal Regulations or laws for the purpose of improving the ability of NATIONAL HEALTH to implement its Congressional Charter. This authority may include proposals for a change in the Congressional Charter for NATIONAL HEALTH excluding any authority to participate in the direct financial reimbursement or any other form of direct economic support for the healthcare of a resident person, excluding any health insurance plan for Associates employed by NATIONAL HEALTH.
F. All public or private institutions interacting with NATIONAL HEALTH shall recognize a single definition for Primary Healthcare as may be defined by NATIONAL HEALTH and for any other related definitions to clarify its meaning.
COMMENT A preliminary definition of Primary Healthcare may be found on the GLOSSARY for HEALTHCARE Sub-Page of the APPENDIX Page.
G. The Board of Trustees shall authorize the Chairman to propose an Operational Statement for the structure and content within the Policies and Procedures of NATIONAL HEALTH. These Operational Statements shall use polycentric and derivative concepts as a basis for governance. The Board of Trustees shall retain ultimate responsibility for the affairs of NATIONAL HEALTH as defined by the Congressional Charter authorization. The Board of Trustees may delegate certain of these responsibilities to its Chairman, or to the Regional Councils.
COMMENT A sample Operational Statement for the GENERAL OPERATING PRINCIPLES may be found on a Sub-Page of the GOALS Page.
H. Decisions of the Board of Trustees, Regional Councils, and District Coalitions shall require a quorum of 5 Members. Any Meeting of a Community HEALTH Forum may not occur without the presence of 5 Advocates, with or without any of their previously identified designees.
I. Three years prior to restarting the Nine Region sequence for appointing Members to the Board of Trustees, the Chairman shall initiate a reconsideration of criteria for assessing the level of healthcare accessibility for each State. Initially, it shall be its maternal mortality ratio as measured over a 10-year interval.
COMMENT As of 2016, the data most recently available was for the years 2005 through 2014. Conceivably, this measurement tool might eventually represent the weighted average of several statistics, as in motor vehicle accident mortality, poverty level, as well as maternal mortality.
J. The deliberations of the Board of Trustees, Regional Councils, and District Coalitions shall follow “Roberts’s Rules of Order, Newly Revised” except when the Chairman declares a temporary Open Collaboration form of deliberation. Each Community HEALTH Forum shall follow an Open Collaboration form of deliberation.
COMMENT No Forum would have the authority or responsibility to directly implement any plan. Their role will reflect only an effort to attain consensus and to monitor the shared responsibility among the principal stakeholders within their own community.
K. The Board of Trustees shall establish an Operational Statement for Special Meetings applicable to itself, the Regional Councils, and the District Councils. This Operational Statement shall also provide recognition of the applicable State laws for
1. the Notice and Limited Agenda Subjects for any closed Special Meeting and
2. any requirements or unique appointments for independent observers.
L. The Board of Trustees shall initiate a Planning Task Force to assess the future evolution of NATIONAL HEALTH starting five years after the initial Meeting of the Board of Trustees and every ten years thereafter. Any possible changes would require a proposal to the President and approved by Congress for the Congressional Charter of NATIONAL HEALTH.